Laserfiche WebLink
Applications W114 Be Processed When Submitted Properlycompieteo. <br /> APPLICATION <br /> FOR OFFICE USE: <br /> ! (For Non-Transferable, Revocable, Suspendable) ( PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT'',rL4 , � y.,�k�l•. / <br /> .., WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSanJoaquinLocalHealthDistrictforapermittoconskructand/orinstalltheworkhereindescribed.Thisapplicationls <br /> R made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Josaqu'n Loc�iPI eaDistrict. <br /> / S }1 �,�d� owe City/Town �� <br /> Exact Site Address - <br /> I Phone <br /> Owner's Name Cit <br /> Address `ts {'� ire yFry/ •ry <br /> License# f 3 771 1 Business Phone— <br /> Contractor's NameC .Y <br /> Contractor's Address Emergency Phone <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJ. HD? Yes—1i- (nt <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIONWELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR <br /> ❑ r <br /> REPLACEMENT❑.. S <br /> ! Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field - _Cesspool page Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE i TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia, of Well Excavation <br /> 1A DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> e' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> l 1:1CATHODIC PROTECTION 11 ROTARY Type of Grout \ <br /> 1 ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> k PUMP INSTALLATION: Contractor f <br /> Ji H.P. <br /> Type of Pump il\ <br /> PUMP REPLACEMENT: ❑ State Work Done I <br /> F PUMP REPAIR: State Work Done <br /> f,,, �. h 1a is f c-lZin _ < <br /> DESTRUCTION OF WELL: µ mQter f <br /> Describe Material and Procedure W <br /> t <br /> r <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the IolIowiliI certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w'I call for a Grout Inspec ' n p r to grow Ing and a final inspectional 0/ <br /> itie: Date: <br /> Signed <br /> (Draw Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date �� I <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill Final Inspection <br /> lnspection By Dake Inspection By Date <br /> ❑ 11,PER UNIT El PER SITE ❑ EACH El January 1 &Received By,January 31 ❑ Juiy 1 &ReceivedByJuly 31 <br /> Fee IS DUE' El ANNUALLY <br /> N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> !� LESS <br /> PRORATIONPLUS <br /> PENALTY <br /> OTHER <br /> Cd <br /> OTHER <br /> - k 4w 1 / f1 EJfif -Int A V <br /> 1_ -v b —� ` YhOi1 t•el <br /> Date leNo. Permit No, <br /> Issuance Date Mailed Delivered I. <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 211 STOCKTON,CA 55201 <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL WEALTH PERMIT/SERVICES , <br />